TWELVE failings of 999 crews that let down Manchester victims as inquiry finds two could have lived

TWELVE failings of 999 crews that let down Manchester victims as inquiry finds two could have lived

The TWELVE key failings of 999 crews that let down Manchester Arena victims – as inquiry finds two could have lived: Communication breakdowns, delays to ambulances and lack of stretchers to evacuate the injured

  • Report today identified litany of failings in the response of emergency services
  • Inquiry chairman found response fell ‘far below the standard it should have been’
  • Bereaved families told two victims could have survived with better treatment  
  • John Atkinson waited an hour and 29 minutes to be placed into an ambulance
  • There is also ‘remote possibility’ Saffie-Rose Roussos, eight, may have survived

A scathing report into the response of emergency services to the Manchester Arena terror attack has identified a litany of failings after communication breakdowns and a lack of stretchers led to delays evacuating victims.

Bereaved families were also told today that two of those who died in the suicide bombing could have survived with better treatment. 

The second of three reports into the attack, led by public inquiry chairman Sir John Saunders, identified that the response from emergency services fell ‘far below the standard it should have been’.

John Atkinson, a care worker from Radcliffe, Greater Manchester, suffered serious leg injuries when the bomb was detonated just six metres away from him.

He was dragged to a footbridge outside the venue and then to a casualty clearing station on the concourse of Victoria railway station. But he had to wait for an hour and 29 minutes to be placed into an ambulance and subsequently suffered a fatal cardiac arrest.

Sir John also said that in the case of the youngest victim, eight-year-old Saffie-Rose Roussos, from Leyland, Lancashire, he could not ‘exclude the possibility’ that she could have been saved.

He said: ‘Significant aspects of the emergency response on May 22, 2017, went wrong. This should not have happened.

‘Some of what went wrong had serious and, in the case of John Atkinson, fatal consequences for those directly affected by the explosion.’

Turning to the youngest victim, he added that although it was ‘highly unlikely that she could have survived her injuries’, there was a ‘remote possibility she could have survived with different treatment and care.’

Sir John highlighted a number of individual failings with police, the ambulance service and firefighters:

A damning report into the response of emergency services to the Manchester Arena terror attack has identified a litany of failings

Saffie-Rose Roussos, eight, from Lancashire, was the youngest victim of the Manchester Arena bombing. She died after suffering leg injuries in the explosion

John Atkinson, 28, a care worker from Radcliffe, suffered significant leg injuries and died died shortly after arriving at the Manchester Royal Infirmary one hour and 35 minutes after the bomb was detonated in the arena foyer

Saffie-Rose Roussos (pictured left) and John Atkinson (right), who were killed in the Manchester Arena bombing which claimed the lives of 22 innocent people could have been saved, a damning report released today has found

Thursday's report by Manchester Arena Inquiry chairman Sir John Saunders pictured outside Manchester Hall yesterday

Thursday’s report by Manchester Arena Inquiry chairman Sir John Saunders pictured outside Manchester Hall yesterday

The 22 victims of the Manchester Arena bombing. Pictured (top row left to right) Off-duty police officer Elaine McIver, 43, Saffie Roussos, 8, Sorrell Leczkowski, 14, Eilidh MacLeod, 14, (second row left to right) Nell Jones, 14, Olivia Campbell-Hardy, 15, Megan Hurley, 15, Georgina Callander, 18, (third row left to right), Chloe Rutherford,17, Liam Curry, 19, Courtney Boyle, 19, and Philip Tron, 32, (fourth row left to right) John Atkinson, 28, Martyn Hett, 29, Kelly Brewster, 32, Angelika Klis, 39, (fifth row left to right) Marcin Klis, 42, Michelle Kiss, 45, Alison Howe, 45, and Lisa Lees, 43 (fifth row left to right) Wendy Fawell, 50 and Jane Tweddle, 51.

The 22 victims of the Manchester Arena bombing. Pictured (top row left to right) Off-duty police officer Elaine McIver, 43, Saffie Roussos, 8, Sorrell Leczkowski, 14, Eilidh MacLeod, 14, (second row left to right) Nell Jones, 14, Olivia Campbell-Hardy, 15, Megan Hurley, 15, Georgina Callander, 18, (third row left to right), Chloe Rutherford,17, Liam Curry, 19, Courtney Boyle, 19, and Philip Tron, 32, (fourth row left to right) John Atkinson, 28, Martyn Hett, 29, Kelly Brewster, 32, Angelika Klis, 39, (fifth row left to right) Marcin Klis, 42, Michelle Kiss, 45, Alison Howe, 45, and Lisa Lees, 43 (fifth row left to right) Wendy Fawell, 50 and Jane Tweddle, 51.

Abedi at Victoria Station making his way to the Manchester Arena, on May 22, 2017, where he detonated his bomb

Abedi at Victoria Station making his way to the Manchester Arena, on May 22, 2017, where he detonated his bomb

A litany of emergency services failings: The 12 key findings from Sir John Saunders second report into the Manchester Arena bombing 

Manchester Arena Inquiry chairman Sir John Saunders highlighted 12 key failures of the emergency response to the May 2017 terror attack. They were:

  • A lack of communication between emergency responders, both through the act of physically co-locating at a single multi-agency RVP (rendezvous point) and via radio.
  • A failure to have available either a multi-agency control room talk group or to set one up on the night. This would have allowed control rooms to speak to each other directly.
  • Failure to have available either a multi-agency control room talk group or to set one up on the night. This would have allowed control rooms to speak to each other directly.
  • Greater Manchester Police’s (GMP) force duty officer (FDO) Inspector Dale Sexton did not inform other emergency services of his declaration of Operation Plato, a pre-determined response to a marauding armed terrorist, or keep it under review.
  • The FDO and others in GMP failed to consider zoning the scene, following the declaration of Operation Plato, in the early stages of the response.
  • No forward command post, for senior officers to liaise, was set up. This was principally the responsibility of GMP, the inquiry found.
  • Delays by North West Ambulance Service (NWAS) in getting ambulances and paramedics to the scene. Failure to send members of NWAS’s specialist Hazardous Area Response Team into the City Room foyer, the scene of the explosion, to assist with triage and life-saving intervention of casualties.
  • Failure to send non-specialist paramedics into the City Room to assist with triage. A failure to get stretchers to the City Room to help evacuate the injured.
  • Greater Manchester Fire and Rescue Service (GMFRS) did not arrive on scene and make any contribution in removing the injured that its officers could have done.
  • Staff at North West Fire Control did not pass on important information to officers in GMFRS.
  • No one in a senior position at GMFRS took a grip of the situation during the critical period of the response

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Ambulance service

Sir John today found that North West Ambulance Service (NWAS) did not deploy ambulances to the arena until nearly 30 minutes after the blast.

Crews were instead initially sent to Manchester Fire Station at a meeting point as the chaos unfolded.

In his report, Sir John said: ‘The failure to dispatch the ambulances already at, and travelling to, Manchester Central Fire Station meant that there were fewer resources available to the NWAS Operational Commander in the first five minutes of his command than there should have been.’

Operational commander Dan Smith decided that non-specialist paramedics should not be deployed into the venue’s City Room foyer, the scene of the explosion.

Sir John said had Mr Smith spoken to the first of only three paramedics to enter the City Room, where Salman Abedi detonated the device, or a police chief at the scene then he would have been informed they regarded it as ‘safe enough’ to work in.

By 10.50pm the City Room was a ‘cold zone’, ruled Sir John, in which it was assessed that there was no immediate threat to life from an armed terrorist.

Two members of the ambulance service’s Hazardous Area Response Team (HART) later followed into the City Room, but Sir John said four others should have joined them.

Sir John said: ‘Police, members of the public and Arena staff used makeshift stretchers to bring down to Victoria station concourse.

‘Daniel Smith believed that the evacuation was going well, and so he thought that he did not need to do anything further.

‘He should have realised that the system for evacuation needed to be improved. Moving casualties in this way was a risk to them. It was painful for many. It risked making injuries worse. The NWAS evacuation plan was inadequate.’

As the post-attack ‘golden hour’ ended, the emergency response had failed to achieve effective evacuation, he continued.

Just after midnight there were still 36 casualties waiting to be taken to hospital – with 29 seriously injured – and it was not until 2.50am on May 23 that the final casualty departed.

Sir John concluded: ‘To those who experienced it, this period of time will have seemed interminable. It must not happen again.

‘One of the most emotional and upsetting parts of the inquiry was listening to the evidence of the people in the City Room, both rescuers and the injured, who heard the sirens of the ambulances outside and expected to see paramedics arriving imminently, and then hearing of their despair when so many fewer than they reasonably expected actually arrived in the City Room.

‘The failure of the paramedics to arrive in numbers was a terrible disappointment to the injured and the rescuers in the City Room who did not have the skills to triage the injured and give them the life-saving medical help they might need prior to be moved. Paramedics had these skills.

Armed police officers pictured beside ambulances outside Manchester Arena following the terrorist attack

Armed police officers pictured beside ambulances outside Manchester Arena following the terrorist attack

Emergency services have been heavily criticised for their response to the terror attack in a scathing report published today

Emergency services have been heavily criticised for their response to the terror attack in a scathing report published today

Daren Mochrie, chief executive of the North West Ambulance Service, said he accepted its findings of the report and 'apologised wholeheartedly'

Daren Mochrie, chief executive of the North West Ambulance Service, said he accepted its findings of the report and ‘apologised wholeheartedly’

‘The injured were desperate for help, not realising that decisions that had been made meant they would not see paramedics in the City Room in the numbers hoped for and expected.

‘The evacuation of the City Room would have worked much better for everyone if there had been a more co-ordinated response.

‘No one wanted the injured and dying to suffer more than they needed. Everyone involved in the emergency no doubt thought that they were doing their best. In some cases, their best was not good enough.’

In response to the scathing report, Daren Mochrie, chief executive of the North West Ambulance Service, said he accepted its findings of the report and ‘apologised wholeheartedly’ for its failures, saying they weighed heavily ‘on us as individuals and us as an organisation’.

He added: ‘For everyone connected with the atrocity on May 22, 2017, the last five years have already produced painful reminders of that night’s events. And although I’m well aware this day has been a long time coming for many – I know the feelings of pain, loss, fear and anger do not go away. 

‘My thoughts and sympathies are with you all, particularly with the bereaved families and the injured. We will never forget the profound impact of the attack on you – every member of the ambulance service, and the communities we serve.

His statement continued: ‘I am confident that if something like this happens again – the response will have more effective preparation, management and coordination between the blue light partners here today. I also believe that everyone at NWAS would strive to respond with professionalism, compassion, and the desire to help.

‘On occasions like this, the word sorry has the risk of sounding hollow. Nevertheless, I want to make it clear that while our actions were well-intentioned, we apologise wholeheartedly for our failures. They weigh heavily on us individually and as an organisation.’

The 22 victims of the Manchester Arena bombing in May 2017 

  • Elaine McIver, 43: the off-duty police officer died in the attack, which injured her husband and children;
  • Saffie-Rose Roussos, eight: the youngest victim was separated from her mother and sister in the seconds after the blast;
  • Sorrell Leczkowski, 14: schoolgirl died in the bomb blast, while her mother, Samantha and grandmother Pauline were badly hurt;
  • Eilidh MacLeod, 14: confirmed dead having been missing since being caught up in the blast with her friend Laura MacIntyre;
  • Nell Jones, 14: farmer’s daughter travelled to the pop concert with her best friend for her 14th birthday;
  • Olivia Campbell-Hardy, 15: her family searched desperately for her for nearly 48 hours and went on TV to plead for news;
  • Megan Hurley, 15: the Liverpool schoolgirl was with her brother who suffered serious injuries in the blast;
  • Georgina Callander, 18: met Ariana Grande backstage at a previous gig and died in hospital with her mother at her bedside;
  • Chloe Rutherford, 17, and Liam Curry, 19: couple from South Shields ‘wanted to be together forever and now they are’, their family said;
  • Courtney Boyle, 19, and Philip Tron, 32: criminology student and her stepfather were confirmed dead following a Facebook appeal;
  • John Atkinson, 28: pop fan from Radcliffe, Greater Manchester, was in a local dance group and was leaving the gig when the blast happened;
  • Martyn Hett, 29: public relations manager from Stockport, who was due to start a two-month ‘holiday of a lifetime’ to the US two days later;
  • Kelly Brewster, 32: civil servant from Sheffield who died trying to shield her 11-year-old niece from the bombing;
  • Marcin Kils, 42, and Angelika Kils, 39: both killed as they waited for their daughters who both survived the blast;
  • Michelle Kiss, 45: mother-of-three from Clitheroe, Lancashire, went to the Ariana Grande concert with her daughter;
  • Alison Lowe, 44, and friend Lisa Lees, 43: both killed when they arrived to pick up their teenage daughters who were not hurt;
  • Wendy Fawell, 50: mother from Leeds was killed by the blast while picking up her children at the Arena with a friend;
  • Jane Taylor, 50: mother-of-three from Blackpool was killed as she waited to collect a friend’s daughter from the concert

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Fire service

A decision to send fire appliances three miles away from the scene of the bombing led to crews not arriving until more than two hours after the incident, the report said today.

Station manager Andy Berry rejected the suggestion by a police inspector at the scene of a rendezvous point at Manchester Cathedral car park, near to the Arena.

Instead, firefighters were sent to Philips Park fire station as they awaited further instructions.

Sir John said: ‘The effect of station manager Berry’s decision to mobilise to Philips Park fire station was that the fire appliances at Manchester Central fire station drove away from, not towards, the incident.

‘While driving away from the incident, the Manchester Central fire appliances drove past ambulances travelling in the opposite direction.’

Mr Berry set off from home to Philips Park, but on his 20-mile journey became lost due to traffic diversions, as Sir John said he was ‘effectively in charge of the GMFRS (Greater Manchester Fire and Rescue Service) response throughout the entire time he was driving’.

Sir John said other GMFRS senior officers who became involved in the response should have acted more decisively before 11.45pm, when someone was finally appointed in command of the incident.

Mr Berry had assumed at an early stage that GMFRS was responding to marauding terrorists and, while in an ‘information vacuum’, he overestimated the risk.

Sir John concluded: ‘There was an apparent unwillingness by other senior officers to intervene as time passed.

‘This was a different sort of aversion to risk. It was an aversion not to danger but to stepping outside of their role.

‘The unavailability of the FDO (Greater Manchester Police’s force duty officer) played a very significant role.

‘Even allowing for this, the response of an entire fire and rescue service should not stall just because one person does not answer the telephone.’

In response to the findings, Greater Manchester Fire and Rescue Service Chief Fire Officer Dave Russel said it had made for ‘very difficult reading’ as he ‘wholeheartedly apologised’ to the bereaved families and the survivors ‘whose live are changed forever’.

In a statement, he said: ‘Our response that night was wholly inadequate and totally ineffective, and that will forever be a matter of deep regret for our Service. We let the families and the public down in their time of need and for that I am truly sorry.

‘I know that no apology will take away the pain and suffering of the families who lost loved ones and of the survivors. But I want them to know that I fully accept the Inquiry’s criticisms of our Service and I accept the recommendations in full. 

‘The inquiry process has been one of the most challenging times in our Service’s history and today is a very difficult day for many, especially those who so desperately wanted to help that night.’

The fire service arrives at Manchester Victoria station after the Arena bomb. Fire crews not arriving until more than two hours after the incident

The fire service arrives at Manchester Victoria station after the Arena bomb. Fire crews not arriving until more than two hours after the incident

In response to the findings, Greater Manchester Fire and Rescue Service Chief Fire Officer Dave Russel said it had made for 'very difficult reading'

In response to the findings, Greater Manchester Fire and Rescue Service Chief Fire Officer Dave Russel said it had made for ‘very difficult reading’

Mr Russel said the service has made ‘significant changes’ to address the failings and ensured ‘this will never happen again’.

He continued: ‘I know the spotlight today is rightly on what our Service got wrong on the night of the attack and I want to reiterate my deepest apologies to the families and survivors. 

‘I want the public to know the same mistakes would not be made today – and have confidence that, never again, will we fall short of what the public should rightly expect of their fire and rescue service.

‘I hope that the public will recognise that Greater Manchester Fire and Rescue Service is a very different organisation today to what it was in 2017, and that the improvements we’ve made – and continue to make – will provide confidence that we are prepared and able to respond to support the people of Greater Manchester when its fire and rescue services are needed.’

Timeline: Key events in the emergency response to the Manchester Arena attack on May 22, 2017

Here is a timeline of the key events in the emergency response in the minutes and hours after the Manchester Arena bombing.

May 22, 2017

6pm – Doors open for the Ariana Grande concert, and the Arena and surrounds begin filling with the 14,000 people attending the show.

9.29pm – Salman Abedi begins his final journey to the City Room, after twice visiting the area earlier in the evening on ‘hostile reconnaissance’.

10.31pm – Abedi detonates his rucksack bomb packed with shrapnel in the packed City Room foyer of the Arena.

Most of the 22 killed die shortly afterwards from unsurvivable injuries. 999 calls are made almost instantly after the blast.

10.34pm – North West Fire Control is first notified of the bombing and mass casualties. They also, wrongly, receive reports of an ‘active shooter’.

10.41pm – Within the first two minutes a British Transport Police (BTP) officer is on scene and within 10 minutes, at least 12 BTP officers had reached or were in the immediate vicinity of the City Room.

10.45pm – Greater Manchester Police (GMP) declare Operation Plato, a pre-planned response to a suspected marauding terrorist firearms attack (MTFA), later proved false.

10.46pm – North West Ambulance Service (NWAS) declare a major incident but believe an active shooter is also on the rampage.

10.50pm – First paramedic arrives on scene in the City Room but is the only one there for the first 40 minutes after the blast.

10.55pm – A BTP officer calls his control room asking: ‘Where’s our ambulances please?’ The controller responds: ‘We don’t know, we are calling them again.’

11.00pm – Ambulances begin to arrive at the Arena but paramedics do not deploy en masse to the City Room.

11.00pm – Sergeant Kam Hare and his team from the Tactical Aid Unit of GMP, who is in the City Room tells a Pc, ‘We need the f****** medics!’

11.02pm – A GMP officer calls his control saying: ‘We need paramedics like f****** yesterday!’

11.10pm – Eight ambulances are by now on scene but only one paramedic actually enters the City Room. Only one person is taken out on a makeshift stretcher in the first 40 minutes.

11.12pm – NWAS Hazardous Area Response Team, with specialist equipment and training arrives 43 minutes after the explosion.

11.17pm – John Atkinson, 28, is evacuated from the City Room on a makeshift stretcher, 46 minutes after the blast, to a triage area at Victoria Station, where he remains for another 24 minutes.

11.23pm – An ambulance transporting Saffie-Rose Roussos arrives at Royal Manchester Children’s Hospital – 52 minutes after the bombing.

11.40pm – Saffie-Rose Roussos is pronounced dead.

11.47pm – John Atkinson goes into cardiac arrest from blood loss as he is taken away from the Arena by ambulance.

11.52pm – The final casualty is evacuated from the City Room on a makeshift stretcher made from cardboard and a crowd barrier, one hour and 20 minutes after the explosion.

May 23

12.24am – John Atkinson is declared dead at Manchester Royal Infirmary.

12.27am – Sgt Hare’s bodycam footage is switched off, shortly before he is recorded saying: ‘F****** hell, we weren’t ready for this, were we.’

12.37am – The first fire engine arrives on scene, two hours and six minutes after the bombing. Some firefighters had been close enough to hear the bomb go off.

1.00am – GMP officially declare a major incident, two and a half hours after the blast.

1.00am – The BTP bronze commander, tasked with co-ordinating events at ground level, arrives at the Arena.

2.05am –  Last casualty departs for hospital.

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Police

The police inspector in initial command of the bombing response ‘quickly became overburdened by the number of tasks he had to undertake’, the public inquiry found.

As Greater Manchester Police’s (GMP) force duty officer (FDO) Inspector Dale Sexton became overwhelmed, it led to a ‘direct impact on the effectiveness’ of the response.

Sir John said: ‘It affected who received information, what resources were made available and the decisions of other commanders.’

He ruled that Inspector Sexton made an early ‘significant” mistake when he failed to declare a major incident – an error compounded by other GMP commanders until the situation was rectified at nearly 1am the next day.

Sir John also criticised the time it took for a tactical/silver commander to arrive at the scene – some 52 minutes after the explosion.

Following erroneous reports of gunshots, Sir John said Mr Sexton correctly declared Operation Plato – a predetermined response to a marauding armed terrorist.

The GMP plan required him to share the declaration with other emergency services, but he failed to so.

‘The burden of his responsibilities as FDO meant that he overlooked it,” Sir John said.

‘The failure to communicate the Operation Plato declaration had significant consequences. It affected the ability of the emergency services to work together by jointly understanding the risks.

‘Op Plato required zones to be applied – the purpose to ensure emergency responders are protected from any terrorists who may be present.

‘There was a substantial failure by GMP at every level of armed command in relation to the zoning of the Victoria Exchange Complex during the ‘golden hour’.

‘By 10.57pm (26 minutes after the blast) the FDO was struggling to manage the different roles that he was required to fulfil. It was difficult for anyone to reach the FDO on the phone.’

Mr Sexton, now retired, told the inquiry he was not overwhelmed and he decided not to tell his emergency service counterparts as he feared they would not send key responders into the City Room.

But Sir John today ruled: ‘I consider that Inspector Sexton was overburdened on the night. He simply had too much to do.’

The inquiry heard evidence about Exercise Winchester Accord in May 2016, which included a mock terror attack at Manchester’s Trafford Centre.

Sir John said the FDO in that exercise was also overwhelmed, particularly in the early stages, and it proved to be a ‘significant missed opportunity’ to plan an adequate and robust response to a similar incident.

In 2016, an Inspectorate of Constabulary and Fire & Rescue Services’ (HMICFRS) inspection took place at GMP on its preparedness for a terror attack, particularly a marauding terrorist attack.

An inspector gave a ‘hot debrief’ to an assistant chief constable in which he told her about the risk that the FDO would become overburdened in an Operation Plato situation and the need for something to be done about this urgently.

Sir John said: ‘It (GMP) had longstanding corporate knowledge of the risk that the FDO would become overburdened in the event that Operation Plato was declared.’

He also criticised the fact there were three Operation Plato plans at GMP by May 22, 2017.

Sir John said: ‘The evidence revealed that different officers, including those who performed vital roles, had different views about which plan was the one that ought to be followed on the night of the attack.

‘The situation that GMP allowed to develop was dangerous. Even if it led to no loss of life on May 22 2017, it was capable of doing so.’

Sir John also noted GMP’s response to an information gathering request from Lord Kerslake who was tasked by Greater Manchester Mayor Andy Burnham in July 2017 to review the emergency response locally.

He said: ‘More than nine months after the attack, the senior leadership of GMP had not realised that the FDO had not communicated the Operation Plato declaration to other emergency services.

‘That was a highly significant fact which should have been identified by GMP at an early stage.’

Greater Manchester Police Chief Constable Stephen Watson apologised ‘unreservedly’ for the force’s failings.

He said: ‘I fully accept the findings of the Chair, Sir John Saunders. 

The police inspector in initial command of the bombing response 'quickly became overburdened by the number of tasks he had to undertake'. Pictured: Officers at the scene

The police inspector in initial command of the bombing response ‘quickly became overburdened by the number of tasks he had to undertake’. Pictured: Officers at the scene

As Greater Manchester Police's (GMP) force duty officer (FDO) Inspector Dale Sexton became overwhelmed, it led to a 'direct impact on the effectiveness' of the response. Pictured: Armed officers at the scene

As Greater Manchester Police’s (GMP) force duty officer (FDO) Inspector Dale Sexton became overwhelmed, it led to a ‘direct impact on the effectiveness’ of the response. Pictured: Armed officers at the scene

Greater Manchester Police Chief Constable Stephen Watson apologised 'unreservedly' for the force's failings

Greater Manchester Police Chief Constable Stephen Watson apologised ‘unreservedly’ for the force’s failings

‘Beyond the selflessness and professionalism of so many of our frontline staff, however, it is also clear that our coordination of the response to this atrocity was inadequate.

‘We had failed to plan effectively, and the execution of that which had been planned, was simply not good enough. 

‘Our actions were substantially inadequate and fell short of what the public had every right to expect. For this, I apologise unreservedly.’ 

Further apologies 

British Transport Police Chief Constable Lucy D’Orsi also released a statement today to apologise to the victims of the terror attack as the failings of emergency services were laid bare.

She said: ‘Significant errors were made in the hours leading up to this horrendous attack and in the immediate aftermath. Our planning and preparation was inadequate to respond to an incident of this magnitude.

‘For those errors, I want to apologise to the families of the victims and to every one of you affected by that terrible night. On behalf of everyone in the British Transport Police – I am truly sorry.

There were mistakes and misjudgements, but there was also compassion and bravery. Police officers and staff who ran towards the attack without hesitation, as well as security staff and members of the public. In the time that has passed, those responders have also carried the trauma of that night. They too, deserve our support.

This is a part of BTP’s history we will never forget. And as you would expect, today’s report does not mark the start of our improvements but acts as an invaluable aid to build on the improvements we have already made – and are continuing to make – since May 2017.

Her statement added: ‘The families and friends of the victims, and the city of Manchester, will continue to grieve for years to come. We share this heartache, not just as an organisation, but as individuals.

‘No learning can turn back the clock. No apology can mend a broken heart. We can only reflect on today’s report with candour, and I promise you, we will do better.

Mayor of Greater Manchester Andy Burnham added: ‘To those injured, to everyone still struggling and, most importantly, to the families of those who died – particularly John’s family and Saffie’s family – I wish to say this very clearly: you were badly let down on that night; you were entitled to expect much better from our emergency services than the response provided; and, as you have heard from them today, everyone here is truly sorry that did not happen.

British Transport Police Chief Constable Lucy D'Orsi said released a statement today to apologise to the victims of the terror attack

British Transport Police Chief Constable Lucy D’Orsi said released a statement today to apologise to the victims of the terror attack

Mayor of Greater Manchester Andy Burnham said the victims of the terror attack 'were badly let down'

Mayor of Greater Manchester Andy Burnham said the victims of the terror attack ‘were badly let down’

‘Of course, there were many people who did act courageously and selflessly in the moment as Sir John said himself today. We recognise what they did. Police officers and paramedics did run into what they believed to be a dangerous situation as did Arena staff, Travel Safe officers and staff from Northern Rail at Victoria Station.

‘In particular, the members of the public who helped others in a desperate situation deserve our huge thanks and more recognition for what they did. Many people in all emergency services did do their jobs properly. But they were let down by the lack of a properly organised response.’

He added: ‘In conclusion, over the last five years, I have had the privilege of getting to know the families who lost loved-ones on that night. They are without exception wonderful people who, as I said at the start, deserved so much better.

‘I have also got to know many of those injured and have seen first-hand how they have come together to help each other, through initiatives such as our incredible Survivors Choir.

‘I hope they all know me well enough by now to know that I would never give them platitudes like “lessons will be learned”.

‘What I can instead say to them today is that major changes have already been made on the back of what happened and more are to come.’ 

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Jamie Phillips

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